The reflex examination includes the deep tendon reflexes (DTRs) and the pathologic reflexes. In testing the deep tendon reflexes, it is important to look for symmetry. DTRs are graded using the following scale:


1—Present but diminished


3—Normal, but brisker than average

4—Increased and pathologic, with one or more beats of clonus

The DTRs assist with localization of a lesion because these reflexes are integrated at different levels of the spinal cord. DTRs help in distinguishing whether a lesion is a UMN lesion with pathologic hyperreflexia or possibly an LMN lesion with hyporeflexia. Table 42-1 summarizes the most important reflexes and their nerve root innervations.

The Babinski sign, or extensor toe sign, is tested by stroking the sole of the foot with a sharp object. A normal response is toe flexion. A pathologic response is extension of the great toe and flaring of the other toes. A positive response is always abnormal in patients older than 3 years and is a sign of pyramidal tract disorder.

Table 42-1 Nerve Root Innervations and Main Reflexes

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